Rethinking human resources: an agenda for the millennium

Physician perspectives on the implications of the diagnosis-related groups for medical practice in Turkey: A qualitative study

Hospital reimbursement models might have unintended consequences for medical practice. In Turkey, a mixed reimbursement scheme, based on the diagnosis‐related group (DRG) model and global budget, was gradually introduced as part of the country's 2003 healthcare reforms. This article examines the impacts of the DRG model on medical practice in Turkey, as perceived by physicians working in public and private hospitals. This study draws on an analysis of 14 interviews with physicians. The findings reveal that the implementation of the DRG has transformed medical practice into a process of cost‐benefit optimisation which involves balancing the income and expenses of hospitals against patients' medical needs. To mitigate the negative effects of the DRG, the current model may need to be reformed, particularly to grant exemptions from the standard reimbursement structure for patients who are experiencing complications and/or multiple health conditions.

The diagnosis‐related group has transformed medical practice in Turkey into a process of optimisation.

Physicians are responsible for balancing hospital budgets against patients' medical needs under the current reimbursement model.

Limited reimbursements for most of healthcare services hinder effective medical practice.

Physicians agree upon the need to increase hospital reimbursement levels by the Social Security Institution.

Visualizing the drivers of an effective health workforce: a detailed, interactive logic model

BACKGROUND

A strong health workforce is a key building block of a well-functioning health system. To achieve health systems goals, policymakers need information on what works to improve and sustain health workforce performance. Most frameworks on health workforce planning and policymaking are high-level and conceptual, and do not provide a structure for synthesizing the growing body of empirical literature on the effectiveness of strategies to strengthen human resources for health (HRH). Our aim is to create a detailed, interactive logic model to map HRH evidence and inform policy development and decision-making.

METHODS

We reviewed existing conceptual frameworks and models on health workforce planning and policymaking. We included frameworks that were: (1) visual, (2) comprehensive (not concentrated on specific outcomes or strategies), and (3) designed to support decision-making. We compared and synthesized the frameworks to develop a detailed logic model and interactive evidence visualization tool.

RESULTS

Ten frameworks met our inclusion criteria. The resulting logic model, available at hrhvisualizer.org , allows for visualization of high-level linkages as well as a detailed understanding of the factors that affect health workforce outcomes. HRH data and governance systems interact with the context to affect how human resource policies are formulated and implemented. These policies affect HRH processes and strategies that influence health workforce outcomes and contribute to the overarching health systems goals of clinical quality, responsiveness, efficiency, and coverage. Unlike existing conceptual frameworks, this logic model has been operationalized in a highly visual, interactive platform that can be used to map the research informing policies and illuminating their underlying mechanisms.

CONCLUSIONS

The interactive logic model presented in this paper will allow for comprehensive mapping of literature around effective strategies to strengthen HRH. It can aid researchers in communicating with policymakers about the evidence behind policy questions, thus supporting the translation of evidence to policy.

Level and Influencing Factors of Job Motivation Among Administrative Staff at Public Hospitals in Vietnam

Administrative staff at healthcare facilities, who are not either doctors or nurses, coordinate, facilitate patient care, and account for 18–20% of human resources in hospitals. Their contribution to the value chain of healthcare service is crucial, but they are not well recognized either by hospital managers and healthcare staff or by patients. Low recognition may cause low job motivation and repeated tasks may cause boredom for them. Our study aimed to assess the level of job motivation among administrative staff in 2 hospitals of Ho Chi Minh city, Vietnam, and explore the influencing factors to job motivation. The exploratory mixed methods design was used in our study with an initial quantitative study with a designed questionnaire and then followed by a qualitative study with focus group discussions. The job motivation index of the administrative staff in our study was not high (4.0). Positive factors were extra income, higher education, healthcare benefits, and a good working environment. Negative factors were low salary index, less chance of higher education, and no separated key performance indicator criteria. The low job motivation index of the administrative staff at public hospitals in our study warns of the negative impact on hospital income in terms of patient satisfaction. In the future, hospitals should have a new strategy in human resource management specifically for administrative staff by maintaining the positive factors and step-by-step overcome the negative factors such as developing separated key performance indicator criteria.

Challenges in day-to-day midwifery practice; a qualitative study from a regional referral hospital in Dar es Salaam, Tanzania

BACKGROUND

Maternal and infant mortality rates in Tanzania have decreased over the past decades, but remain high. One of the challenges the country faces, is the lack of skilled health care workers. High fertility rates make midwives and their patients particularly susceptible to stress as a result of understaffing.

OBJECTIVE

This paper explores the challenges midwives face in their day-to-day practice at a regional referral hospital in Tanzania, and investigates which measures the midwives themselves find necessary to implement to improve their situation.

METHODS

A qualitative study design with focus group discussions (FGDs) was employed to explore which challenges the midwives experienced. Each focus group consisted of five to six midwives. A FGD topic guide covering challenges, consequences, motivation, ideal situation and possible solutions was used. These data were analyzed using Systematic Text Condensation.

RESULTS

A total of 28 Midwives, six men and 22 women, participated in five FGDs. Four categories emerged from the collected material: Feelings of demoralization, shortage of resources, societal challenges and personal struggles. A feeling of demoralization was especially prevalent and was caused by a lack of support from the leaders and little appreciation from the patients. Shortage of resources, and shortage of personnel in particular, was also highlighted as it led to an excessive workload resulting in difficulties with providing adequate care. These difficulties were intensified by lack of equipment, facilities and a non-optimal organization of the healthcare system.

CONCLUSION

The challenges revealed during the FGDs prevent the midwives from providing sufficient midwifery care. To improve the situation, measures such as supportive leadership, reduction of workload, increasing availability of equipment and increasing knowledge of reproductive health in society, should be taken.

Postings and transfers in the Ghanaian health system: a study of health workforce governance

BACKGROUND

Decision-making on postings and transfers - that is, the geographic deployment of the health workforce - is a key element of health workforce governance. When poorly managed, postings and transfers result in maldistribution, absenteeism, and low morale. At stake is managing the balance between organisational (i.e., health system) and individual (i.e., staff preference) needs. The negotiation of this potential convergence or divergence of interests provides a window on practices of postings and transfers, and on the micro-practices of governance in health systems more generally. This article explores the policies and processes, and the interplay between formal and informal rules and norms which underpin postings and transfers practice in two rural districts in the Greater Accra Region of Ghana.

METHODS

Semi-structured interviews were conducted with eight district managers and 87 frontline staff from the district health administration, district hospital, polyclinic, health centres and community outreach compounds across two districts. Interviews sought to understand how the postings and transfers process works in practice, factors in frontline staff and district manager decision-making, personal experiences in being posted, and study leave as a common strategy for obtaining transfers.

RESULTS

Differential negotiation-spaces at regional and district level exist and inform postings and transfers in practice. This is in contrast to the formal cascaded rules set to govern decision-making authority for postings and transfers. Many frontline staff lack policy clarity of postings and transfers processes and thus 'test' the system through informal staff lobbying, compounding staff perception of the postings and transfers process as being unfair. District managers are also challenged with limited decision-space embedded in broader policy contexts of systemic hierarchy and resource dependence. This underscores the negotiation process as ongoing, rather than static.

CONCLUSIONS

These findings point to tensions between individual and organisational goals. This article contributes to a burgeoning literature on postings and transfers as a distinct dynamic which bridges the interactions between health systems governance and health workforce development. Importantly, this article helps to expand the notion of health systems governance beyond 'good' governance towards understanding governance as a process of negotiation.

Relationships of work characteristics to job satisfaction, turnover intention, and burnout among doctors in the district public-private mixed health system of Bangladesh

Background

Work design integrates work characteristics having organizational, social and job components which influence employees’ welfare and also organizational goals. We investigated the effects of work characteristics and other predictors to job satisfaction, turnover intention, and burnout in doctors of the public primary, public secondary and private facilities of the district health system of Bangladesh.

Methods

A quantitative study using a self-administered questionnaire containing mostly structured items was conducted among the public and private doctors with a sample size of 384 from 29 out of a total 64 districts of Bangladesh during October and November 2015. All variables including work characteristics and outcomes of interest were based on literature and measured on 5-point Likert scale. Multivariate analysis of variance, bivariate correlation, and multiple regression were the models operated through SPSS version-21.

Results

A total of 354 doctors responded. No significant differences were found between public primary and secondary level doctors on combined work characteristics and outcomes variables, which however differed significantly between the public and private doctors. Organizational support was the strongest predictor adversely affecting job satisfaction, turnover intention and burnout of both the public and private doctors; private doctors’ experienced more support. The effects of health-professional politics on the public doctors were alarming.

Conclusion

Work design of the Bangladesh’s health system is in need of ample development. Doing so, improvement in organizational supports is crucial; however, other work characteristics components are also important for enhancing doctors’ welfare and health system productivity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2369-y) contains supplementary material, which is available to authorized users.

The impact of demographic and situational factors on training transfer in a health care setting

Training transfer is the extent to which human resource development (HRD) interventions result in a change in trainee workplace behaviour post-training. Training transfer is an important dimension of training effectiveness. However, studies on training transfer are not extensive and some of the findings are inconclusive. Drawing on a study of 124 trainees across 102 similar organisations within the Irish health care system, the current study investigates the effect of demographic variables (age, educational background, position), situational variables (time since training, tenure, recruitment to the training programme, preparation for training) and organisational size on training transfer. Regression analyses report that current position significantly impacts training transfer in terms of direction, while method of recruitment to the training programme, age and employment tenure were all significant predictors of training transfer complexity. The findings report that age is not a barrier to training transfer. These results have important implications for HRD practitioners with regard to the profile of the workforce in this setting, the training and development function and trainee recruitment.

Health worker posting and transfer at primary level in Tamil Nadu: Governance of a complex health system function

Background:

Posting and transfer (PT) of health personnel – placing the right health workers in the right place at the right time – is a core function of any large-scale health service. In the context of government health services, this may be seen as a simple process of bureaucratic governance and implementation of the rule of law. However the literature from India and comparable low and middle-income country health systems suggests that in reality PT is a contested domain, driven by varied expressions of private and public interest throughout the chain of implementation.

Objective:

To investigate policymaking for PT in the government health sector and implementation of policies as experienced by different health system actors and stakeholders at primary health care level.

Methodology:

We undertook an empirical case study of a PT reform policy at primary health care level in Tamil Nadu State, to understand how different groups of health systems actors experience PT. In-depth qualitative methods were undertaken to study processes of implementation of PT policies enacted through ‘counselling’ of health workers (individualized consultations to determine postings and transfers).

Results:

PT emerges as a complex phenomenon, shaped partially by the laws of the state and partially as a parallel system of norms and incentives requiring consideration and coordination of the interests of different groups. Micro-practices of governance represent homegrown coping mechanisms of health administrators that reconcile public and private interests and sustain basic health system functions. Beyond a functional perspective of PT, it also reflects justice and fairness as it plays out in the health system. It signifies how well a system treats its employees, and by inference, is an index of the overall health of the system.

Conclusions:

For a complex governance function such as PT, the roles of private actors and private interests are not easily separable from the public, but rather are intertwined within the complexities of delivery of a public service. This complexity blurs conventional boundaries of private and public ownership and behaviour, and raises critical questions for the interpretation of coordinated governance. Hence, the imperative of enforcing rules may need to be complemented with bottom-up policy approaches, including treating PT not merely as system dysfunction, but also as a potential instrument of governance innovations, procedural justice and the accountability of health services to communities they seek to serve.

Redesigning a Ministry of Health's organizational structure: exploring implementation challenges through Botswana's experiences

INTRODUCTION

The Botswana's Ministry of Health redesigned and adopted a new organizational structure in 2005, which was poorly implemented. This article explores factors that influenced the implementation of this organizational structure.

METHODS

This article draws from data collected through in-depth interviews with 54 purposively selected key informants comprising policy makers, senior managers and staff of the Ministry of Health (N = 40) and senior officers from various stakeholder organizations (N = 14).

FINDINGS

Participants generally felt that the review of the Ministry of Health organizational structure was important. The previous structure was considered obsolete with fragmented functions that limited the overall performance of the health system. The new organizational structure was viewed to be aligned to current national priorities with potential to positively influence performance. Some key weaknesses identified included lack of consultation and information sharing with workers during the restructuring process, which affected the understanding of their new roles, failure to mobilize key resources to support implementation of the new structure and inadequate monitoring of the implementation process.

CONCLUSION

Redesigning an organizational structure is a major change. There is a need for effective and sustained leadership to plan, direct, coordinate, monitor and evaluate the implementation phase of the reform. Copyright © 2014 John Wiley & Sons, Ltd.

The assessment of job satisfaction for the healthcare providers in university clinics of Lubumbashi, Democratic Republic of Congo

INTRODUCTION

In the world, the health policies are necessary to satisfy with efficiency the requirements of the quality management in the health sector. The laboratory of the academic clinics of Lubumbashi in Africa was inspired by the EFQM model to improve its performance and the quality of its services offered to the community. The aim of this survey is to evaluate the level of job satisfaction of the healthcare providers after implementation of the model.

METHODS

Qualitative study used an anonymous questionnaire consisted of 16 semi directional dichotomous and 12 according to four modality of the Likert's scale; to evaluate the job satisfaction of the healthcare providers. 40 workers are concerned and their informed consent is obtained. Epi Info 3.5.3 and SPSS 19.0 software, the Student t test and Chi-square test and the threshold set at p ≤ 0.05 were used. The mean score was calculated. Cronbach's ' coefficient and principal component analysis allowed the validity measurement of the questionnaire, and the correlations has been calculated.

RESULTS

This survey had a rate of answer of 80% on a set of all questionnaires. The Cronbach's coefficient of reliability is 0.72 on 40 complete observations with 12 questions. The Kaiser Meyer Olkin (0.564) and the Bartlett test is significant (χ(2)= 57, 30, p=0.001). The Physicians are very dissatisfied (2.363) against the nurses, and the biologists who are moderately dissatisfied (3 and 3.312). The relative results to the global satisfaction of the workers show a meaningful difference between the workers satisfied versus those non satisfied (p = 0.003). More of the half of the workers is satisfied after the setting up of the EFQM model.

CONCLUSION

A certain number of the factors act together and simultaneously on the satisfaction of the workers particular in the health sector. The EFQM model permits the job satisfaction in the hospital because it combines several factors acting on the individuals.

Level of motivation amongst health personnel working in a tertiary care government hospital of new delhi, India

Aims:

To assess the level and factors of motivation amongst permanent government employees working in a tertiary health care institution.

Material and Methods:

A sample of 200 health personnel (50 in each category) i.e. doctors, nurses, technician, and support staff were contacted through face to face interview. Motivation was measured as the degree to which an individual possessed various identified motivation domains like Drive, Control, Challenge, Relationship and Rewards. Each domain was represented by 4 dimensions- accordingly a closed-ended statement represented each of these dimensions and responses were assessed on a Likert based scale. Data management was done using SPSS, ver. 19.

Results:

The average age for different health personnel were: Doctors 48.68 (±8.53), nurses 40.72 (±7.76), technician 38.4 (±10.65) and support staff 43.24 (±9.52) years. The average year of work experience was: Doctor 19.09 (±9.77), nurses 17.2 (±8.420), technician 14.84 (±10.45), support staff 18.24 (±10.28). A comparison of overall motivation index (mean score) revealed that nurse had highest level (3.47), followed by support staff (3.46), doctor (3.45) and technician (3.43). Based on their individual mean scores, the healthcare providers were categorised into three different levels of motivation and it was found that majority of the health personnel i.e.70% of support staff, 62% nurse, 56% doctor and technician, had high to very high level of motivation index. The mean scores for all the five factors as well as their respective ranks were also found out and it was deduced that “relationship” assumed first rank for doctors (mean score: 3.71) and technician (mean score: 3.75), whereas “control” assumed greatest significance for nurses (mean score, 3.62) and support staff (mean scores, 3.61). Based upon the mean scores, “reward” assumed third rank among all the four categories. Kruskal-Wallis test was applied to test if the different categories of health personnel varied with respect to five factors of motivation and it was found that their orientation towards the various motivational components differed significantly only with respect to Drive (P < 0.01).

Conclusion:

There is scope for enhancing staff motivation.

Human resource management in post-conflict health systems: review of research and knowledge gaps

In post-conflict settings, severe disruption to health systems invariably leaves populations at high risk of disease and in greater need of health provision than more stable resource-poor countries. The health workforce is often a direct victim of conflict. Effective human resource management (HRM) strategies and policies are critical to addressing the systemic effects of conflict on the health workforce such as flight of human capital, mismatches between skills and service needs, breakdown of pre-service training, and lack of human resource data. This paper reviews published literatures across three functional areas of HRM in post-conflict settings: workforce supply, workforce distribution, and workforce performance. We searched published literatures for articles published in English between 2003 and 2013. The search used context-specific keywords (e.g. post-conflict, reconstruction) in combination with topic-related keywords based on an analytical framework containing the three functional areas of HRM (supply, distribution, and performance) and several corresponding HRM topic areas under these. In addition, the framework includes a number of cross-cutting topics such as leadership and governance, finance, and gender. The literature is growing but still limited. Many publications have focused on health workforce supply issues, including pre-service education and training, pay, and recruitment. Less is known about workforce distribution, especially governance and administrative systems for deployment and incentive policies to redress geographical workforce imbalances. Apart from in-service training, workforce performance is particularly under-researched in the areas of performance-based incentives, management and supervision, work organisation and job design, and performance appraisal. Research is largely on HRM in the early post-conflict period and has relied on secondary data. More primary research is needed across the areas of workforce supply, workforce distribution, and workforce performance. However, this should apply a longer-term focus throughout the different post-conflict phases, while paying attention to key cross-cutting themes such as leadership and governance, gender equity, and task shifting. The research gaps identified should enable future studies to examine how HRM could be used to meet both short and long term objectives for rebuilding health workforces and thereby contribute to achieving more equitable and sustainable health systems outcomes after conflict.

Health workforce in the United Arab Emirates: analytic point of view

A strong health system is impossible without health workers who are the ultimate resource. Money and medical supplies are needed, but these inputs require an efficient workforce. Challenges with respect to human resources vary greatly between and within countries, and are associated with the political, economical, cultural and societal context of a country. Moreover, the gaps in the workforce do not generally relate to doctors but to nurses and other classes of health worker who make up the bulk of health workforce. The difficulties caused by low staff numbers are compounded by morale problems, skill imbalances and geographical maldistribution. This paper will discuss how it is difficult for the United Arab Emirates (UAE, a Middle East federation country) to wrestle effectively with the demands of a good health system, exploring how they lack the basis of health systems-motivated, trained and supported people. Additionally, we looked at how the UAE health system further challenged by negative work environment, and weak knowledge-base, out-migration and inadequate investment. At the end of our discussion, we are providing some suggestions to manage human resource problems in the UAE. Highlighting how a national workforce strategic plan is important to guide investments in human resources as the core component of strengthening the UAE national health system.

Maximizing the benefit of health workforce secondment in Botswana: an approach for strengthening health systems in resource-limited settings

To address health systems challenges in limited-resource settings, global health initiatives, particularly the President’s Emergency Plan for AIDS Relief, have seconded health workers to the public sector. Implementation considerations for secondment as a health workforce development strategy are not well documented. The purpose of this article is to present outcomes, best practices, and lessons learned from a President’s Emergency Plan for AIDS Relief-funded secondment program in Botswana. Outcomes are documented across four World Health Organization health systems’ building blocks. Best practices include documentation of joint stakeholder expectations, collaborative recruitment, and early identification of counterparts. Lessons learned include inadequate ownership, a two-tier employment system, and ill-defined position duration. These findings can inform program and policy development to maximize the benefit of health workforce secondment. Secondment requires substantial investment, and emphasis should be placed on high-level technical positions responsible for building systems, developing health workers, and strengthening government to translate policy into programs.

Coherence between health policy and human resource strategy: lessons from maternal health in Vietnam, India and China

The failure to meet health goals such as the Millennium Development Goals (MDG) is partly due to the lack of appropriate resources for the effective implementation of health policies. The lack of coherence between the health policies and human resource (HR) strategy is one of the major causes. This article explores the relationship and the degree of coherence between health policy--in this case maternal health policy--processes and HR strategy in Vietnam, China and India in the period 2005-09. Four maternal health policy case studies were explored [skilled birth attendance (SBA), adolescent and sexual reproductive health, domestic violence and medical termination of pregnancy] across three countries through interviews with key respondents, document analysis and stakeholder meetings. Analysis for coherence between health policy and HR strategy was informed by a typology covering 'separation', 'fit' and 'dialogue'. Regarding coherence we found examples of complete separation between health policy and HR strategy, a good fit with the SBA policy though modified through 'dialogue' in Vietnam, and in one case a good fit between policy and strategy was developed through successive evaluations. Three key influences on coherence between health policy and HR strategy emerge from our findings: (1) health as the lead sector, (2) the nature of the policy instrument and (3) the presence of 'HR champions'. Finally, we present a simple algorithm to ensure that appropriate HR related actors are involved; HR is considered at the policy development stage with the option of modifying the policy if it cannot be adequately supported by the available health workforce; and ensuring that HR strategies are monitored to ensure continued coherence with the health policy. This approach will ensure that the health workforce contributes more effectively to meeting the MDGs and future health goals.

Reliability and validity analysis of modified Nursing Stress Scale for Indian population

The original Nursing Stress Scale (NSS) was structurally modified according to results of factorial analysis and a new scale was named as modified nursing stress scale (MNSS). This is the first study to modify and validate NSS for Indian nursing population. Factorial analysis showed different factor loading for two subscales and items were shifted according to their loading to provide a more meaningful structure. After relocation of Items 13, 14, and 15 into first factor, this factor was renamed as "emotional and painful conditions of patients" to provide a more appropriate name to the first factor. Items 24, 25, 26, 27, 28, and 29 were found to be distributed under two different factors; one of these two was renamed as "unpredictable changes" and another retained its original name (i.e., workload). This distribution was also supported by rational analysis. All other items were distributed under factors as in the original scale. Rest of the validity assessment was done with the modified scale. Thus, with minor changes in structure, the scale was found to have better content validity.

Corruption in the health care sector: A barrier to access of orthopaedic care and medical devices in Uganda

Background

Globally, injuries cause approximately as many deaths per year as HIV/AIDS, tuberculosis and malaria combined, and 90% of injury deaths occur in low- and middle- income countries. Given not all injuries kill, the disability burden, particularly from orthopaedic injuries, is much higher but is poorly measured at present. The orthopaedic services and orthopaedic medical devices needed to manage the injury burden are frequently unavailable in these countries. Corruption is known to be a major barrier to access of health care, but its effects on access to orthopaedic services is still unknown.

Methods

A qualitative case study of 45 open-ended interviews was conducted to investigate the access to orthopaedic health services and orthopaedic medical devices in Uganda. Participants included orthopaedic surgeons, related healthcare professionals, industry and government representatives, and patients. Participants’ experiences in accessing orthopaedic medical devices were explored. Thematic analysis was used to analyze and code the transcripts.

Results

Analysis of the interview data identified poor leadership in government and corruption as major barriers to access of orthopaedic care and orthopaedic medical devices. Corruption was perceived to occur at the worker, hospital and government levels in the forms of misappropriation of funds, theft of equipment, resale of drugs and medical devices, fraud and absenteeism. Other barriers elicited included insufficient health infrastructure and human resources, and high costs of orthopaedic equipment and poverty.

Conclusions

This study identified perceived corruption as a significant barrier to access of orthopaedic care and orthopaedic medical devices in Uganda. As the burden of injury continues to grow, the need to combat corruption and ensure access to orthopaedic services is imperative. Anti-corruption strategies such as transparency and accountability measures, codes of conduct, whistleblower protection, and higher wages and benefits for workers could be important and initial steps in improving access orthopaedic care and OMDs, and managing the global injury burden.

Public and private sector in the health care system of the Federation bosnia and herzegovina: policy and strategy

In Bosnia and Herzegovina citizens receive health care from both public and private providers. The current situation calls for a clear government policy and strategy to ensure better position and services from both parts. This article examines how health care services are delivered, particularly with respect to relationship between public and private providers. The paper notes that the public sector is plagued by a number of weaknesses in terms of inefficiency of services provision, poorly motivated staff, prevalent dual practice of public employees, poor working conditions and geographical imbalances. Private sector is not developing in ways that address the weaknesses of the public sector. Poorly regulated, it operates as an isolated entity, strongly profit-driven. The increasing burdens on public health care system calls for government to abandon its passive role and take action to direct growth and use potential of private sector. The paper proposes a number of mechanisms that can be used to influence private as well as public sector, since actions directed toward one part of the system will inevitable influence the other.

Educating a new generation of doctors to improve the health of populations in low- and middle-income countries

Francesca Celletti and colleagues from WHO argue that a transformation in the scale-up of medical education in low- and middle-income countries is needed, and detail what this might look like.

Levels of Job Satisfaction among Healthcare Providers in CGHS Dispensaries

In the labour-intensive health sector industry the quality of services is ultimately linked to the skills, motivation and satisfaction of the workers providing the healthcare services. Thus in order to study the job satisfaction level of the healthcare providers, so as to suggest measures to enhance it, the present study was carried out at CGHS which is one of the biggest public health sector organisations in the country and caters to a huge section of the organised sector.

Understanding the healthcare provider’s work satisfaction is crucial to the understanding of the dynamics of the healthcare provider’s work force. Job satisfaction has been shown to be important in the retention of the healthcare providers in a given community as low job satisfaction has been associated with an intention to relocate. Recent studies have reported that low levels of job satisfaction among healthcare providers affect the patient-provider relationship and also compromise the quality of healthcare services. The study was undertaken to assess the levels of job satisfaction among the healthcare providers in CGHS dispensaries.

A standardised tool developed by Peter Warr, John Cook and Toby Wall (1979) was used to measure the healthcare providers’ job satisfaction in the present study. For this study 250 healthcare providers working in the CGHS dispensaries of Delhi were interviewed. This included 100 doctors, 50 nurses and 100 paramedics which included both pharmacists and lab technicians. The findings of this study indicated that the levels of job satisfaction were not very high among the healthcare providers who were interviewed.

Identifying priority healthcare trainings in frozen conflict situations: The case of Nagorno Karabagh

INTRODUCTION

Health care in post-war situations, where the system's human and fixed capital are depleted, is challenging. The addition of a frozen conflict situation, where international recognition of boundaries and authorities are lacking, introduces further complexities.

CASE DESCRIPTION

Nagorno Karabagh (NK) is an ethnically Armenian territory locked within post-Soviet Azerbaijan and one such frozen conflict situation. This article highlights the use of evidence-based practice and community engagement to determine priority areas for health care training in NK. Drawing on the precepts of APEXPH (Assessment Protocol for Excellence in Public Health) and MAPP (Mobilizing for Action through Planning and Partnerships), this first-of-its-kind assessment in NK relied on in-depth interviews and focus group discussions supplemented with expert assessments and field observations. Training options were evaluated against a series of ethical and pragmatic principles.

DISCUSSION AND EVALUATION

A unique factor among the ethical and pragmatic considerations when prioritizing among alternatives was NK's ambiguous political status and consequent sponsor constraints. Training priorities differed across the region and by type of provider, but consensus prioritization emerged for first aid, clinical Integrated Management of Childhood Illnesses, and Adult Disease Management. These priorities were then incorporated into the training programs funded by the sponsor.

CONCLUSIONS

Programming responsive to both the evidence-base and stakeholder priorities is always desirable and provides a foundation for long-term planning and response. In frozen conflict, low resource settings, such an approach is critical to balancing the community's immediate humanitarian needs with sponsor concerns and constraints.

Hospital management autonomy in Chile: the challenges for human resources in health

In Latin America, some health sector reforms have included steps to the implementation of autonomous hospitals. In Chile, the health system is implementing a reform that introduces a network of self-managed institutions. These organizations will be high complexity centers that involve greater technical diversity, cost centers and mechanisms to evaluate users' satisfaction. For human resources in health, the implementation of these centers creates challenges in the planning of service provision and a change from the traditional management style of the teams to one based on networks. These challenges include the estimation of gaps in medical specialists and in other professions in the health sector. In order to be successful with self-management, Chile needs to establish universal and local policies that address training and the organization of health service provisioning in these institutions.

From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management

Throughout the world, countries are experiencing shortages of health care workers. Policy-makers and system managers have developed a range of methods and initiatives to optimise the available workforce and achieve the right number and mix of personnel needed to provide high-quality care. Our literature review found that such initiatives often focus more on staff types than on staff members' skills and the effective use of those skills. Our review describes evidence about the benefits and pitfalls of current approaches to human resources optimisation in health care. We conclude that in order to use human resources most effectively, health care organisations must consider a more systemic approach--one that accounts for factors beyond narrowly defined human resources management practices and includes organisational and institutional conditions.

Developing a tool to measure health worker motivation in district hospitals in Kenya

BACKGROUND

We wanted to try to account for worker motivation as a key factor that might affect the success of an intervention to improve implementation of health worker practices in eight district hospitals in Kenya. In the absence of available tools, we therefore aimed to develop a tool that could enable a rapid measurement of motivation at baseline and at subsequent points during the 18-month intervention study.

METHODS

After a literature review, a self-administered questionnaire was developed to assess the outcomes and determinants of motivation of Kenyan government hospital staff. The initial questionnaire included 23 questions (from seven underlying constructs) related to motivational outcomes that were then used to construct a simpler tool to measure motivation. Parallel qualitative work was undertaken to assess the relevance of the questions chosen and the face validity of the tool.

RESULTS

Six hundred eighty-four health workers completed the questionnaires at baseline. Reliability analysis and factor analysis were used to produce the simplified motivational index, which consisted of 10 equally-weighted items from three underlying factors. Scores on the 10-item index were closely correlated with scores for the 23-item index, indicating that in future rapid assessments might be based on the 10 questions alone. The 10-item motivation index was also able to identify statistically significant differences in mean health worker motivation scores between the study hospitals (p<0.001). The parallel qualitative work in general supported these conclusions and contributed to our understanding of the three identified components of motivation.

CONCLUSION

The 10-item score developed may be useful to monitor changes in motivation over time within our study or be used for more extensive rapid assessments of health worker motivation in Kenya.

Assessment of human resources for health using cross-national comparison of facility surveys in six countries

BACKGROUND

Health facility assessments are being increasingly used to measure and monitor indicators of health workforce performance, but the global evidence base remains weak. Partly this is due to the wide variability in assessment methods and tools, hampering comparability across and within countries and over time. The World Health Organization coordinated a series of facility-based surveys using a common approach in six countries: Chad, Côte d'Ivoire, Jamaica, Mozambique, Sri Lanka and Zimbabwe. The objectives were twofold: to inform the development and monitoring of human resources for health (HRH) policy within the countries; and to test and validate the use of standardized facility-based human resources assessment tools across different contexts.

METHODS

The survey methodology drew on harmonized questionnaires and guidelines for data collection and processing. In accordance with the survey's dual objectives, this paper presents both descriptive statistics on a number of policy-relevant indicators for monitoring and evaluation of HRH as well as a qualitative assessment of the usefulness of the data collection tool for comparative analyses.

RESULTS

The findings revealed a large diversity in both the organization of health services delivery and, in particular, the distribution and activities of facility-based health workers across the sampled countries. At the same time, some commonalities were observed, including the importance of nursing and midwifery personnel in the skill mix and the greater tendency of physicians to engage in dual practice. While the use of standardized questionnaires offered the advantage of enhancing cross-national comparability of the results, some limitations were noted, especially in relation to the categories used for occupations and qualifications that did not necessarily conform to the country situation.

CONCLUSION

With increasing experience in health facility assessments for HRH monitoring comes greater need to establish and promote best practices regarding methods and tools for their implementation, as well as dissemination and use of the results for evidence-informed decision-making. The overall findings of multi-country facility-based survey should help countries and partners develop greater capacity to identify and measure indicators of HRH performance via this approach, and eventually contribute to better understanding of health workforce dynamics at the national and international levels.

Human resources for health at the district level in Indonesia: the smoke and mirrors of decentralization

BACKGROUND

In 2001 Indonesia embarked on a rapid decentralization of government finances and functions to district governments. One of the results is that government has less information about its most valuable resource, the people who provide the services. The objective of the work reported here is to determine the stock of human resources for health in 15 districts, their service status and primary place of work. It also assesses the effect of decentralization on management of human resources and the implications for the future.

METHODS

We enumerated all health care providers (doctors, nurses and midwives), including information on their employment status and primary place of work, in each of 15 districts in Java. Data were collected by three teams, one for each province.

RESULTS

Provider density (number of doctors, nurses and midwives/1000 population) was low by international standards--11 out of 15 districts had provider densities less than 1.0. Approximately half of all three professional groups were permanent public servants. Contractual employment was also important for both nurses and midwives. The private sector as the primary source of employment is most important for doctors (37% overall) and increasingly so for midwives (10%). For those employed in the public sector, two-thirds of doctors and nurses work in health centres, while most midwives are located at village-level health facilities.

CONCLUSION

In the health system established after Independence, the facilities established were staffed through a period of obligatory service for all new graduates in medicine, nursing and midwifery. The last elements of that staffing system ended in 2007 and the government has not been able to replace it. The private sector is expanding and, despite the fact that it will be of increasing importance in the coming decades, government information about providers in private practice is decreasing. Despite the promise of decentralization to increase sectoral "decision space" at the district level, the central government now has control over essentially all public sector health staff at the district level, marking a return to the situation of 20 years ago. At the same time, Indonesia has changed dramatically. The challenge now is to envision a new health system that takes account of these changes. Envisioning the new system is a crucial first step for development of a human resources policy which, in turn, will require more information about health care providers, public and private, and increased capacity for human resource planning.

Innovation and motivation in public health professionals

OBJECTIVES

Innovations in public health services promote increases in the health status of the population. Therefore, it is a major concern for health policy makers to understand the drivers of innovation processes. This paper focuses on the differences in behaviour of managers and front-line employees in the pro-innovative provision of public health services.

METHODS

We utilize a survey conducted on front-line employees and managers in public health institutions across six European countries. The survey covers topics related to satisfaction, or attitude towards innovation or their institution. We undertake principal components analysis and analysis of variance, and estimate a multinomial ordered probit model to analyse the existence of different behaviour in managers and front-line employees with respect to innovation.

RESULTS

Perception of innovation is different for managers and front-line employees in public health institutions. While front-line employees' attitude depends mostly on the overall performance of the institution, managers feel more involved and motivated, and their behaviour depends more on individual and organisational innovative profiles.

CONCLUSION

It becomes crucial to make both managers and front-line employees at public health institutions feel participative and motivated in order to maximise the benefits of technical or organisational innovative process in the health services provision.

Human resource management in the Georgian National Immunization Program: a baseline assessment

BACKGROUND

Georgia's health care system underwent dramatic reform after gaining independence in 1991. The decentralization of the health care system was one of the core elements of health care reform but reports suggest that human resource management issues were overlooked. The Georgian national immunization program was affected by these reforms and is not functioning at optimum levels. This paper describes the state of human resource management practices within the Georgian national immunization program in late 2004.

METHODS

Thirty districts were selected for the study. Within these districts, 392 providers and thirty immunization managers participated in the study. Survey questionnaires were administered through face-to-face interviews to immunization managers and a mail survey was administered to immunization providers. Qualitative data collection involved four focus groups. Analysis of variance (ANOVA) and Chi-square tests were used to test for differences between groups for continuous and categorical variables. Content analysis identified main themes within the focus groups.

RESULTS

Weak administrative links exist between the Centres of Public Health (CPH) and Primary Health Care (PHC) health facilities. There is a lack of clear management guidelines and only 49.6% of all health providers had written job descriptions. A common concern among all respondents was the extremely inadequate salary. Managers cited lack of authority and poor knowledge and skills in human resource management. Lack of resources and infrastructure were identified as major barriers to improving immunization.

CONCLUSION

Our study found that the National Immunization Program in Georgia was characterized by weak organizational structure and processes and a lack of knowledge and skills in management and supervision, especially at peripheral levels. The development of the skills and processes of a well-managed workforce may help improve immunization rates, facilitate successful implementation of remaining health care reforms and is an overall, wise investment. However, reforms at strategic policy levels and across sectors will be necessary to address the systemic financial and health system constraints impeding the performance of the immunization program and the health care system as a whole.

The international migration of Indian nurses

AIM

To identify the factors responsible for the international migration of Indian nurses.

METHODS

The paper is based on the responses of 448 nurse practitioners, nurse educators and nurse administrators to a questionnaire administered to them in December 2004-January 2005. Key factors were identified by the analysis of contingency tables.

DISCUSSION

Apart from economic factors, dissatisfaction with working conditions and unhappiness with prevalent social attitudes towards nurses were identified as being of crucial importance for the international migration of Indian nurses. It was found that nurses working in the private sector and from some linguistic and religious groups were particularly prone to migration. Nurses working in the government sector seemed to be more worried about being unable to adjust to working conditions abroad, and therefore less keen to migrate. The fact that they enjoyed better pay scales, a more relaxed work atmosphere and more facilities may have also played a part here. What seemed to be vital to the decision to migrate for a large number of government sector nurses belonging to the so-called 'Forward' and 'Middle' Castes was that they were being crowded out of promotional avenues as a result of the government's policy of Reservations in Promotions for Scheduled Castes and Tribes.

CONCLUSION

Health policy-makers in India need to take a serious look at the growing migration of nurses to foreign countries. While such migration leads to inflow of foreign exchange, it also implies the loss of medical personnel vital for the fulfilment of national goals.

Does decentralisation improve human resource management in the health sector? A case study from China

A major obstacle to the provision of health services is lack of an effective workforce. Human resource management (HRM) can improve the effectiveness of the workforce, though this is difficult in large bureaucratic organisations. Decentralisation is a common reform strategy and this paper sets out to examine whether HRM would be improved in decentralised settings. Indicators were developed for three areas of HR outcome: (i) appropriate staff numbers, with (ii) appropriate skills and experience, providing, (iii) appropriate inputs to organisational performance. An attempt was made to link these human resource (HR) outcomes to relevant HRM actions in two counties--one richer and one poorer--in Fujian Province, China. One general county hospital and 5 township health centres were selected for study in each country. A health facility-based survey collected information on characteristics of the workforce and staff surveys identified changes in the management of human resources and staff inputs to performance before and after decentralisation. Whilst some benefits were identified from decentralising HRM, the complexity of the decentralisation itself, and other external pressures coupled with inadequate capacity building meant that some HRM actions were not always aligned with health service objectives. Better planning and preparation coupled with strong monitoring would increase the chances of decentralisation improving HRM in the health sector.

The performance of health workers in Ethiopia: Results from qualitative research

Insufficient attention has been paid to understanding what determines the performance of health workers. This paper reports on findings from focus group discussions with both health workers and users of health services in Ethiopia, a country with some of the poorest health outcomes in the world. We describe performance problems identified by both health users and health workers participating in the focus group discussions, including absenteeism and shirking, pilfering drugs and materials, informal health care provision and illicit charging, and corruption. In the second part of the paper we present four structural reasons why these problems arise: (i) the ongoing transition from health sector dominated by the public sector, towards a more mixed model; (ii) the failure of government policies to keep pace with the transition towards a mixed model of service delivery; (iii) weak accountability mechanisms and the erosion of professional norms in the health sector; and (iv) the impact of HIV/AIDS. The discussions underline the need to base policies on a micro-analysis of how health workers make constrained choices, both in their career and in their day to day professional activities.

Imbalances in the health labour force: an assessment using data from three national health facility surveys

Accurate knowledge of the characteristics of the health labour force that can affect health care production is of critical importance to health planners and policymakers. This study uses health facility survey data to examine characteristics of the primary health care labour force in Nicaragua, Tanzania and Bangladesh. The characteristics examined are those that are likely to affect service provision, including urban/rural distribution, demographic characteristics, and experience and in-service training, for three types of providers (physicians, nurses and auxiliary nurses). The profiles suggest a pattern of urban/rural imbalances in Nicaragua and Tanzania. The Bangladesh facility survey did not include hospitals, thereby making concrete conclusions on the supply and distribution of providers difficult to make. Multivariate logistic regressions are used to assess the relationship between the urban/rural placement of providers by health need, population demand and facility characteristics. Health need, as measured by child mortality rates, does not have a significant association with the placement of providers in either country, unlike population size and annual growth rates. The mean number of years providers have worked at a facility is significantly associated with a decreased likelihood of rural placement for the three types of providers in Nicaragua. The mean age and percentage of female providers at each facility has a negative association with the placement of rural providers in Tanzania. The use of health facility data to profile the health care labour force is also discussed.

The impact of hospital management reforms on absenteeism in Costa Rica

The reduction of high levels of absenteeism among health care workers was one the objectives of the reforms undertaken to improve public hospital performance during the 1990s in Costa Rica. This paper attempts to assess the impact of changes in reimbursement methods and organizational reform on absence rates among health care personnel in Costa Rican public hospitals for the period 1995-2001. Our results show the reforms to have had a negative impact on absenteeism, which increased throughout the considered period. Results further indicate that the policy of not substituting absentee workers, which was introduced through the reforms, did not work as expected in a permissive environment in which peer pressure mechanisms were lacking. In addition, the explicit incentives for workers included in the reforms were retained and used at facility level. There is a pressing need in the future for control and disciplinary mechanisms for health care personnel and for the introduction of absence rates as an explicit goal to be monitored and evaluated.

Public sector reform and demand for human resources for health (HRH)

This article considers some of the effects of health sector reform on human resources for health (HRH) in developing countries and countries in transition by examining the effect of fiscal reform and the introduction of decentralisation and market mechanisms to the health sector.Fiscal reform results in pressure to measure the staff outputs of the health sector. Financial decentralisation often leads to hospitals becoming "corporatised" institutions, operating with business principles but remaining in the public sector. The introduction of market mechanisms often involves the formation of an internal market within the health sector and market testing of different functions with the private sector. This has immediate implications for the employment of health workers in the public sector, because the public sector may reduce its workforce if services are purchased from other sectors or may introduce more short-term and temporary employment contracts.Decentralisation of budgets and administrative functions can affect the health sector, often in negative ways, by reducing resources available and confusing lines of accountability for health workers. Governance and regulation of health care, when delivered by both public and private providers, require new systems of regulation.The increase in private sector provision has led health workers to move to the private sector. For those remaining in the public sector, there are often worsening working conditions, a lack of employment security and dismantling of collective bargaining agreements.Human resource development is gradually being recognised as crucial to future reforms and the formulation of health policy. New information systems at local and regional level will be needed to collect data on human resources. New employment arrangements, strengthening organisational culture, training and continuing education will also be needed.

Imbalance in the health workforce

Imbalance in the health workforce is a major concern in both developed and developing countries. It is a complex issue that encompasses a wide range of possible situations. This paper aims to contribute not only to a better understanding of the issues related to imbalance through a critical review of its definition and nature, but also to the development of an analytical framework. The framework emphasizes the number and types of factors affecting health workforce imbalances, and facilitates the development of policy tools and their assessment. Moreover, to facilitate comparisons between health workforce imbalances, a typology of imbalances is proposed that differentiates between profession/specialty imbalances, geographical imbalances, institutional and services imbalances and gender imbalances.

[The nursing labour market in Canada (1985-1999)]

This literature review analysed both published and unpublished scientific and professional studies on the nursing labour market in Canada within the period of 1985 to 1999. The goal was to conduct a situational analysis utilising statistical data and canvassing all concerned parties to extract their points of view. The analysis revealed significant cyclical variations in the evolution of the workforce, particularly with respect to auxiliary nurses, such as the perceived existence of major problems in recruiting new professionals in the field and retaining existing professionals in their organisations, the lack of homogeneity in educational training programmes, and the co-existence of several operational structures for organising nursing care, of which there is a lack of evaluation on their effectiveness. The results of the literature review identify the necessity to further develop the knowledge base on such a relevant dimension of the nursing labour market.

Informed choices for attaining the Millennium Development Goals: towards an international cooperative agenda for health-systems research

Health systems constraints are impeding the implementation of major global initiatives for health and the attainment of the Millennium Development Goals (MDGs). Research could contribute to overcoming these barriers. An independent task force has been convened by WHO to suggest areas where international collaborative research could help to generate the knowledge necessary to improve health systems. Suggested topics encompass financial and human resources, organisation and delivery of health services, governance, stewardship, knowledge management, and global influences. These topics should be viewed as tentative suggestions that form a basis for further discussion. This article is part of a wide-ranging consultation and comment is invited. The potential agenda will be presented at the Ministerial Summit on Health Research in November, 2004, and revised in the light of responses. Subsequently, we hope that resources will be committed to generate the evidence needed to build the equitable, effective, and efficient health systems needed to achieve the MDGs

What difference does ("good") HRM make?

The importance of human resources management (HRM) to the success or failure of health system performance has, until recently, been generally overlooked. In recent years it has been increasingly recognised that getting HR policy and management "right" has to be at the core of any sustainable solution to health system performance. In comparison to the evidence base on health care reform-related issues of health system finance and appropriate purchaser/provider incentive structures, there is very limited information on the HRM dimension or its impact.Despite the limited, but growing, evidence base on the impact of HRM on organisational performance in other sectors, there have been relatively few attempts to assess the implications of this evidence for the health sector. This paper examines this broader evidence base on HRM in other sectors and examines some of the underlying issues related to "good" HRM in the health sector.The paper considers how human resource management (HRM) has been defined and evaluated in other sectors. Essentially there are two sub-themes: how have HRM interventions been defined? and how have the effects of these interventions been measured in order to identify which interventions are most effective? In other words, what is "good" HRM?The paper argues that it is not only the organisational context that differentiates the health sector from many other sectors, in terms of HRM. Many of the measures of organisational performance are also unique. "Performance" in the health sector can be fully assessed only by means of indicators that are sector-specific. These can focus on measures of clinical activity or workload (e.g. staff per occupied bed, or patient acuity measures), on measures of output (e.g. number of patients treated) or, less frequently, on measures of outcome (e.g. mortality rates or rate of post-surgery complications).The paper also stresses the need for a "fit" between the HRM approach and the organisational characteristics, context and priorities, and for recognition that so-called "bundles" of linked and coordinated HRM interventions will be more likely to achieve sustained improvements in organisational performance than single or uncoordinated interventions.

Responding to the global human resources crisis

The global community is in the midst of a growing response to health crises in developing countries, which is focused on mobilising financial resources and increasing access to essential medicines. However, the response has yet to tackle the most important aspect of health-care systems--the people that make them work. Human resources for health--the personnel that deliver public-health, clinical, and environmental services--are in disarray and decline in much of the developing world, particularly in sub-Saharan Africa. The reasons behind this disorder are complex. For decades, efforts have focused on building training institutions. What is becoming increasingly clear, however, is that issues of supply, demand, and mobility (transnational, regional, and local) are central to the human-resource problem. Without substantial improvements in workforces, newly mobilised funds and commodities will not deliver on their promise. The global community needs to engage in four core strategies: raise the profile of the issue of human resources; improve the conceptual base and statistical evidence available to decision makers; collect, share, and learn from country experiences; and begin to formulate and enact policies at the country level that affect all aspects of the crisis.

Determinants and consequences of health worker motivation in hospitals in Jordan and Georgia

Health worker motivation reflects the interactions between workers and their work environment. Because of the interactive nature of motivation, local organizational and broader sector policies have the potential to affect motivation of health workers, either positively or negatively, and as such to influence health system performance. Yet little is known about the key determinants and outcomes of motivation in developing and transition countries. This exploratory research, unique in its broader study of a whole range of motivational determinants and outcomes, was conducted in two hospitals in Jordan and two in Georgia. Three complementary approaches to data collection were used: (1) a contextual analysis; (2) a qualitative 360-degree assessment; and (3) a quantitative in-depth analysis focused on the individual determinants and outcomes of the worker's motivational process. A wide range of psychometric scales was used to assess personality differences, perceived contextual factors and motivational outcomes (feelings, thoughts and behaviors) on close to 500 employees in each country. Although Jordan and Georgia have very different cultural and socio-economic environments, the results from these two countries exhibited many similarities among key determinants: self-efficacy, pride, management openness, job properties, and values had significant effects on motivational outcomes in both countries. Where results were divergent, differences between the two countries highlight the importance of local culture on motivational issues, and the need to tailor motivational interventions to the specific issues related to particular professional or other groupings in the workforce. While workers themselves state that financial reward is critical for their work satisfaction, the data suggest a number of non-financial interventions that may be more effective means to improve worker motivation. This research highlights the complexity of worker motivation, and the need for a more comprehensive approach to increasing motivation, satisfaction and performance, and for interventions at both organizational and policy levels.

Uses of population census data for monitoring geographical imbalance in the health workforce: snapshots from three developing countries

Background

Imbalance in the distribution of human resources for health (HRH), eventually leading to inequities in health services delivery and population health outcomes, is an issue of social and political concern in many countries. However, the empirical evidence to support decision-making is often fragmented, and many standard data sources that can potentially produce statistics relevant to the issue remain underused, especially in developing countries. This study investigated the uses of demographic census data for monitoring geographical imbalance in the health workforce for three developing countries, as a basis for formulation of evidence-based health policy options.

Methods

Population-based indicators of geographical variations among HRH were extracted from census microdata samples for Kenya, Mexico and Viet Nam. Health workforce statistics were matched against international standards of occupational classification to control for cross-national comparability. Summary measures of inequality were calculated to monitor the distribution of health workers across spatial units and by occupational group.

Results

Strong inequalities were found in the geographical distribution of the health workforce in all three countries, with the highest densities of HRH tending to be found in the capital areas. Cross-national differences were found in the magnitude of distributional inequality according to occupational group, with health professionals most susceptible to inequitable distribution in Kenya and Viet Nam but less so in Mexico compared to their associate professional counterparts. Some discrepancies were suggested between mappings of occupational information from the raw data with the international system, especially for nursing and midwifery specializations.

Conclusions

The problem of geographical imbalance among HRH across countries in the developing world holds important implications at the local, national and international levels, in terms of constraints for the effective deployment, management and retention of HRH, and ultimately for the equitable delivery of health services. A number of advantages were revealed of using census data in health research, notably the potential for producing detailed statistics on health workforce characteristics at the sub-national level. However, lack of consistency in the compilation and processing of occupational information over time and across countries continues to hamper comparative analyses for HRH policy monitoring and evaluation.

Developing evidence-based ethical policies on the migration of health workers: conceptual and practical challenges

It is estimated that in 2000 almost 175 million people, or 2.9% of the world's population, were living outside their country of birth, compared to 100 million, or 1.8% of the total population, in 1995. As the global labour market strengthens, it is increasingly highly skilled professionals who are migrating. Medical practitioners and nurses represent a small proportion of highly skilled workers who migrate, but the loss of health human resources for developing countries can mean that the capacity of the health system to deliver health care equitably is compromised. However, data to support claims on both the extent and the impact of migration in developing countries is patchy and often anecdotal, based on limited databases with highly inconsistent categories of education and skills.The aim of this paper is to examine some key issues related to the international migration of health workers in order to better understand its impact and to find entry points to developing policy options with which migration can be managed.The paper is divided into six sections. In the first, the different types of migration are reviewed. Some global trends are depicted in the second section. Scarcity of data on health worker migration is one major challenge and this is addressed in section three, which reviews and discusses different data sources. The consequences of health worker migration and the financial flows associated with it are presented in section four and five, respectively. To illustrate the main issues addressed in the previous sections, a case study based mainly on the United Kingdom is presented in section six. This section includes a discussion on policies and ends by addressing the policy options from a broader perspective.

Human resources for health in Palestine: a policy analysis. Part II. The process of policy formulation and implementation

This article is the presentation of part II of the analysis aiming at providing an insight and better understanding of human resources for health development within a conflicting and transitional context. This part focuses on the human resources for health (HRH) policy development in Palestine taking into consideration the critical elements in policy formulation and implementation, such as sound data based policy and planning, key stakeholders, role and implications of international cooperation. Moreover, it examines recent progress of HRH policy and constraints for implementation. Part I addresses the current situation and recent developments in HRH in Palestine.

Human resources for health in Palestine: a policy analysis. Part I: Current situation and recent developments

Human Resources for Health Development (HRD) has been a priority and focus of attention in the Palestinian healthcare system since the changeover of authority on the system at the end of 1994. This analysis examines HRD between 1994 and 2001. The aim is to provide an insight into and better understanding of the issue in a conflicting and transitional context. The results of this analysis are presented in two parts. Part I looks at the current situation and recent developments in Human Resources for Health (HRH) in Palestine. On the one hand, it analyses the relationship between HRH deficiencies and major policy options and strategies. On the other hand, it examines the correlation between HRH policy development and the policy context. Particular attention is given to the links between national health policy priorities and health sector reform initiatives. Part II focuses on the process of HRH policy formulation and implementation.